To evaluate the effect of a patient, health care provider, and systems intervention on the prevalence of risk factors for lower extremity amputation in patients with non-insulin-dependent diabetes. Blinded, randomized, controlled trial. Academic general medicine practice. Of the 395 patients with non-insulin-dependent diabetes who underwent the initial patient assessment, 352 completed the study. The 12-month intervention was multifaceted. Patients received foot-care education and entered into a behavioral contract for desired self-foot care, which was reinforced through telephone and postcard reminders. Health care providers were given practice guidelines and informational flow sheets on foot-related risk factors for amputation in diabetic patients. In addition, the folders for intervention patients had special identifiers that prompted health care providers to: 1) ask that patients remove their footwear, 2) perform foot examinations, and 3) provide foot-care education. Patients receiving the intervention were less likely than control patients to have serious foot lesions (baseline prevalence, 2.9%; odds ratio, 0.41 [95% CI, 0.16 to 1.00]; P = 0.05) and other dermatologic abnormalities. Also, they were more likely to report appropriate self-foot-care behaviors, to have foot examinations during office visits (68% compared with 28%; P < 0.001), and to receive foot-care education from health care providers (42% compared with 18%; P < 0.001). Physicians assigned to intervention patients were more likely than physicians assigned to control patients to examine patients' feet for ulcers, pulses, and abnormal dermatologic conditions and to refer patients to the podiatry clinic (10.6% compared with 5.0%; P = 0.04). An intervention designed to reduce risk factors for lower extremity amputations positively affected patient self-foot-care behavior as well as the foot care given by health care providers and reduced the prevalence of lower extremity clinical disease in patients with diabetes.

PURPOSE: To examine an instrument for evaluating clinical teaching using factor analysis and to refine the validated instrument to a practical length. METHOD: Factor analysis on a split sample of 1,581 student evaluations rating 178 teachers. The instrument was based on the seven-category Stanford Faculty Development Program's (SFDP's) clinical teaching framework and contained 58 Likert-scaled items, with at least seven items per category plus five items measuring “teacher's knowledge.” Standard methodology for survey item reduction was used to remove items with low or complex factor loadings and iteratively remove items with low item-scale correlation. Results were replicated on the second sample. RESULTS: The seven original categories emerged and items originally categorized under “knowledge” statistically combined with “promoting self-directed learning.” Over 73% of the variance was explained. Item reduction resulted in 25 items with overall internal consistency over .97 and internal consistency of constructs ranging from .82 to .95. CONCLUSIONS: Factor analysis of student ratings validated the seven-category SFDP framework. An abbreviated instrument to measure the seven categories is described. Results suggest that students may not systematically distinguish between their teachers' knowledge and their teachers' ability to promote self-directed learning, an important finding for both administrators and faculty development programs.

OBJECTIVE To identify and quantify independent physiological risk factors for foot lesions in diabetic patients. RESEARCH DESIGN AND METHODS There were 352 patients enrolled in a 1-year randomized controlled trial aimed at reducing risks for lower-extremity pathology through patient education and system interventions. Inclusion criteria were as follows: being age 40 years or over, being at or above ideal body weight, and having been diagnosed with NIDDM. Participants were predominantly African-American (76%), elderly (mean 60 years of age), indigent (77% with annual income < $10,000), or women (81%) who had diabetes for 10 years. Prospective multivariate modeling used baseline clinical signs (e.g., blood pressure, dermatological characteristics, and neuropathic measures) and laboratory values (e.g., lipid profiles and measures of glycemic control) to predict foot lesions rated using the Seattle Wound Classification. RESULTS When controlling for intervention effects, only measures of neuropathy (monofilament testing [odds ratio {OR} 2.75, 95% CI 1.55–4.88] and thermal sensitivity testing [2.18, 1.13–4.21]) predicted wounds classified 1.2 (minor injury), but investigation of wounds rated at least 1.3 (nonulcerated lesions) indicated baseline wounds (13.41), 3.19–56.26), monofilament abnormalities (5.23, 2.26–12.13), and low HDL (1.63, 1.11–2.39) as predictors. Although fungal dermatitis, dry cracked skin, edema, ingrown nails, microalbuminuria, fasting blood glucose, and hemoglobin A_1c were candidates for one or both of the multivariable models (P < 0.3), they were not significant multivariate predictors. CONCLUSIONS Lesions may be preventable with aggressive screening for peripheral neuropathy and abnormal lipids. Also, these results provide empirical support for the commonly held belief that foot lesions prospectively predict future wounds.